LIFE IN THE END ZONE: A discussion of topical issues for anyone concerned with the final phase of life by Muriel R. Gillick, MD

May 07, 2017

Falling Down on the Job

In
the sixties, physicians routinely prescribed bed rest for patients who had
suffered a heart attack. Then along came the recognition that bed rest led to
clot formation in the lower extremities, clots that sometimes broke off and
traveled to the lungs, causing potentially life-threatening pulmonary emboli.
Bed rest also led to deconditioning—when patients finally were allowed to get
up, they found they were often weak and wobbly. And so bed rest was out and
early mobilization was in. But now, concurrent with a vigorous attempt to
prevent falls among older hospitalized patients, bed rest is back in—and with
more complications than ever, as reported in a thoughtful article in JAMA Internal Medicine last week.

In
2008, in response to the observation that “injurious falls” were responsible
for increased hospital costs and were clearly bad for patients, the Centers for
Medicare and Medicaid Services introduced a program incentivizing hospitals to
prevent falls. Currently, a fall resulting in significant injury (such as a
fracture) is one of eight hospital-acquired conditions that collectively determine
whether hospitals will be penalized for poor performance. To address the CMS
initiative, hospitals introduced a variety of techniques designed to keep older
patients from falling such as bed alarms and “fall risk” signs on the door.
According to Growdon and colleagues, the result has been a “national epidemic
of immobility among hospitalized older adults.”

Paradoxically,
the means used by hospitals to prevent falls don’t work. Bed (and chair) alarms
are ineffective—which is not entirely surprising, as by the time a nurse
responds to the buzzer indicating the patient has gotten out of bed (or chair),
the person is probably already on the floor. Even a multi-prong study from
Australia using a variety of different approaches simultaneously was
unsuccessful.

But
all those bed alarms and signs on the door do achieve something, and that’s to
keep patients at bed rest. And just as bed rest was bad for heart attack
patients in the sixties, it’s bad for older patients today. Bed rest promotes
the development of confusion (delirium) and worsens mobility, so when patients
finally do get out of bed, either late in their hospital stay or after they get
home, they are more likely to fall.

Growdon,
a resident in internal medicine at a major Boston teaching hospital, and his
colleagues at a VA Hospital in Florida and at Hebrew Senior Life, a teaching
nursing home, are rightfully indignant. They advocate promoting mobility rather
than penalizing falls, arguing that “although hospital falls can lead to harm,
treating them as ‘never events’ has led to over implementation of measures with
little efficacy for falls [prevention] yet profound contribution to
immobility.” They are, no doubt, correct. But why? Why should an incentive
program based on outcomes lead to the adoption of a strategy that does not lead
to the desired outcome?

If
CMS had used a process measure, if it had offered extra payments to
hospitals that introduced fall prevention programs, I wouldn't have been surprised that it resulted
in hospitals adopting programs for the sake of having something, regardless of
efficacy. But instead it opted to penalize hospitals for performing poorly, which should by rights have led to hospitals choosing to take steps that made a difference. What is it about the culture
of hospitals or the leadership of hospital CEOs or the knowledge base of
physicians and nurses that lets them make such irrational choices?

I
wish I knew the answer. In the meantime, perhaps CMS would do well to offer
carrots rather than sticks, and to be specific about the kind of carrots that
it likes the most. If programs that promote mobility work, directives to get patients out of bed early and to consult physical therapy—both to prevent falls
and to maintain function—then it’s those specific programs it should endorse
and pay for.

1 comment:

Thanks for posting this. Your insight that, despite all the attention, the techniques, protocols and training still not getting to the heart of patient falls. I am not a clinician, but a family caregiver and for my money, the issue is that the equipment used to help patients with mobility and self-care for activities such as self-toileting DO NOT support FUNCTIONAL INDEPENDENCE or SELF-CARE. Rather than wait for staff to assist, many patients and families visiting will initiate unsafe activity using equipment with substandard design. I believe that a call for optimizing the functional/self-care level during an in-patient visit also spills over to the post-acute caregivng experience. Yet clinicians tend to be dismissive of equipment as an actionable input for treating their patients, perhaps because they see "for-profit" companies ready to take advantage in a manner similar to pharmaceutical companies. They would rather keep care planning within the frame of their own skill set rather than demand better equipment.